S_BUC_19 | Lexipedia

Approved

International Process Guidelines

Sickness Sector

S_BUC_19 – Actual cost claim - Benefits in kind

Date: 11/09/2018

Version of guidelines document: v4.1.0

Based on: S_BUC_14a version 4.1.0

Common Data Model version: 4.1.0

TABLE OF CONTENTS

S_BUC_19 – Actual cost claim - Benefits in kind 4

How to start this BUC? 5

What is my role in the social security exchange of information I have to complete? 5

CO.1 Who do I need to notify? 5

CO.2 How do I identify the correct institution(s) to exchange information with? 5

CO.3 How do I proceed after having identified the Counterparty? 5

CO.4 How do I proceed after receiving 'Contestation of Credit note'- SED S087? 6

CO.5 How do I proceed after receiving 'Information on payment of individual claim'' - SED S091? 6

CO.6 How do I proceed after receiving 'Information on down payments' - SED S089? 6

CO.7 How do I proceed after receiving 'Contestation of individual claim' - SED S082? 7

CO.8 How do I create 'Credit Note – SED S085' 7

CP.1 What should I do if I have received the 'Claim for reimbursement'- SED S080? 7

CP.2 What should I do if I have received the 'Reply to information on down payments' - SED S090? 8

CP.3 What should I do if I have received the 'Acknowledgement of contestation of individual claim' - SED S083? 8

CP.4 What should I do if I have received the 'Acknowledgement of payment of single claim' - SED S092? 8

CP.5 What should I do if I have received the 'Reply to contestation of individual claim' - SED S084? 8

CP.6 What should I do if I have received the 'Credit note' - SED S085? 8

CP.7 What should I do if I have received the 'Reply to contestation of credit note' - SED S088? 9

BPMN diagram for S_BUC_19 10

Structured Electronic Documents (SEDs) used in the process 10

Administrative sub-processes 10

Document history:

Revision

Date

Created by

Short Description of Changes

V0.1

07/07/2017

Secretariat

First draft of the document submitted for review to the Sickness Ad Hoc group

V0.2

06/11/2017

Secretariat

Comments received from AHG integrated.

V0.99

04/12/2017

Secretariat

Implemented changes and updates following the AC review. Version submitted for AC approval

V1.0

20/12/2017

Secretariat

AC approved version.

Comments from Finland received by writing as follow up of AC meeting integrated

V4.1.0

11/09/2018

Secretariat

Performed patch changes to reference the new CDM version 4.1.0

S_BUC_19 – Actual cost claim - Benefits in kind

Description: This BUC depicts the business transactions of a reimbursement based on actual costs.

Legal Base: The Business Use Case document's legal base is described in the following Regulations

Basic Regulation (EC) No 883/2004

Implementing Regulation (EC) No 987/2009.

The following matrix specifies the SEDs that are used in this Business Use Case and documents the articles that provide the legal basis for each SED.

SED

Basic Regulation

(883/04)

Implementing Regulation

(987/09)

S080 Claim for reimbursement (CLA)

S081 Acknowledgment of claim for reimbursement (ACK_CLA)

S082 Contestation of individual claim (COC)

S083 Acknowledgement of contestation of individual claim (ACK_COC)

S084 Reply on contestation of individual claim (RPY_COC)

S085 Credit note (CRN)

S087 Contestation of Credit note (COC_CRN)

S088 Reply on contestation of Credit note (RPY_COC_CRN)

S089 Information on down payments (IDP)

S090 Reply to information on down payments (RPY_IDP)

S091 Information on payment of individual claim (PAY)

S092 Acknowledgement of payment of single claim (ACK_PAY)

Glossary of relevant terms used in S_BUC_19:

Term used

Description

Case Owner

In this BUC the Case Owner is the Creditor Institution's Liaison Body of the Member State of Residence or Stay that claims reimbursement of benefits in kind on the basis of actual costs on behalf of a Creditor Institution.

Counterparty

In this BUC the Counterparty is the Debtor Institution's Liaison Body of the Competent Member State that replies for the claim of a reimbursement payment on the basis of actual cost on behalf of a Debtor Institution.

How to start this BUC?

In order to help you understand the S_BUC_19 we have created a set of questions that will guide you through the main scenario of the process, as well as possible sub-scenarios or options available at each step along the way. Ask yourself each question and click on one of the hyperlinks that will guide you to the answer in the next step within this document or to another separate file. You will notice that in some of the steps, where it is allowed to use the additional horizontal and administrative

sub-processes, they will be listed under the step description.

What is my role in the social security exchange of information I have to complete?

If you are a Creditor Institution's Liaison Body of the Member State of Residence or Stay that claims reimbursement of benefits in kind on the basis of actual costs on behalf of a Creditor Institution, then your role will be defined as the Case Owner.

I am the Case Owner. (step CO.1)

If you are the Debtor Institution's Liaison Body of the Competent Member State that replies for the claim of a reimbursement on the basis of actual cost on behalf of a Debtor Institution, then your role will be defined as the Counterparty.

I am the Counterparty. (step CP.1)

CO.1 Who do I need to notify?

As the Case Owner, your first step in any new exchange of information will be to identify the Member State that you need to exchange information with. The second step is to identify the relevant institution (Liaison body of the Member State of Residence or Stay) in this Member State that is responsible to treat the information you sent. In this Business Use Case, the institution can be chosen only among the institutions (Liaison body of the Member State of Residence or Stay) responsible for health insurance. This activity will define the Counterparty you will be working with.

Please note that there can only be one Counterparty in this Business Use Case.

I need to identify the Counterparty (step CO.2)

I have identified the Counterparty I need to contact. (step CO.3)

CO.2 How do I identify the correct institution(s) to exchange information with?

In order to determine the relevant Competent Institution from other Member State you will need to consult the Institution Repository (IR). The IR provides an electronic record of all current and previous Competent Institutions and Liaison Bodies that have been responsible for the cross border coordination of social security information for each of the relevant Member States.

Please note that reimbursement occur only between Liaison Bodies.

To access the IR please use the following link.

I have now identified the Competent Institution(s) from the Member State(s) I need to contact. (step CO.3)

CO.3 How do I proceed after having identified the Counterparty?

There will only be one Counterparty identified. You have to fill out the 'Claim for reimbursement' – SED S080 by entering all required global and individual claim information on the basis of actual cost, and send it to the Counterparty.

The Counterparty receives it and creates 'Acknowledgment of claim for reimbursement' – SED S081, confirming the receipt of the request, then sends it to you.

Optionally, after sending SED S080, at any time in the process, you may fill out 'Credit note' – SED S085

whereby you inform the debtor institution about correction of the amount of initial claim in SED S080 that you sent.

Depending on the circumstances of the case, any of the following steps may occur / can be taken:

I have received 'Acknowledgement of Claim for Reimbursement - Benefits in Kind'- SED S081(step CO.4)

How do I create ‘'Credit Note – Benefits in kind - SED S085’ (step CO.5)

Optionally, after receiving “Acknowledgment of claim for reimbursement' – SED S081” you may receive: "Information on payment of individual claim – SED S091", "Information on down payment – SED S089", "Contestation of individual claim –SED S082" or you may create and send the "Credit Note – SED S085"

What should I do If I receive “Information on payment of individual claim – SED S091. (step CO.5)

What should I do If I receive “Information on down payment – SED S089. (step CO. 6)

What should I do If I receive “Contestation of individual claim –SED S082. (step CO. 7)

How do I create ‘'Credit Note - SED S085 (step CO.8)

CO.4 How do I proceed after receiving 'Contestation of Credit note'- SED S087?

If you have received 'Contestation of credit note' - SED 087, you have to fill out 'Reply to contestation of credit note' – SED S088, and give information about the reply to contestations of credit notes and send SED S088 to the Counterparty.

The Counterparty receives 'Reply to contestation of credit note' - SED S088.

The credit note process ends here.

CO.5 How do I proceed after receiving 'Information on payment of individual claim'' - SED S091?

You can receive 'Information on payment of individual claim' - SED S091, from the Counterparty whereby they inform you about the schedule for payment. A specific payment announcement always refers to a specific 'Claim for reimbursement' - SED 080.

Exceptionally, several payment notifications can be pooled into one single payment order. An actual transfer of the money is done outside the system.

The SED S091 only provides the information, which invoices will be paid.

Then you have to create 'Acknowledgment of payment of single claim' – SED S092 confirming the receipt of the payment for a claim and send it to the Counterparty. The date of the payment is the value date of the transaction as introduced by the banking institution of your Liaison Body. The Counterparty receives SED S092 and the business use case ends here.

Alternatively you might receive from the Counterparty the SED S082

What should I do If I receive “Contestation of individual claim –SED S082. (step CO. 7)

CO.6 How do I proceed after receiving 'Information on down payments' - SED S089?

You can receive 'Information on down payment' – SED S089 from the Counterparty to make a down payment on the claims submitted in 'Claim for reimbursement' - SED S080. The exact amount of the down payment is determined by the details in the global note claim of SED S080 and it has to reach at least 90 % of the total amount of the global claim and down payment should be made within 6 months of the end of the month during which the claim was introduced.

Then you have to fill out 'Reply to information on down payment' – SED S090, informing the Counterparty whether the offer is accepted or not. If the offer is accepted, the amount agreed upon should be processed for payment. Send it to the Counterparty.

Alternatively, you could also receive from the Counterparty the SEDs S082 or S091.

What should I do If I receive “Information on payment of individual claim – SED S091. (step CO.5)

What should I do If I receive “Contestation of individual claim –SED S082. (step CO. 7)

CO.7 How do I proceed after receiving 'Contestation of individual claim' - SED S082?

The Counterparty may optionally fill out 'Contestation of individual claim' – SED S082, where the debtor state notifies the amount to be contested and the reason for refusal.

If you receive SED S082, optionally with relevant attachments, you have to fill out 'Acknowledgment of contestation of individual claim' – SED S083, confirming the receipt of the contestation of a claim and send it to the Counterparty.

After having sent the SED S083, you have to fill out 'Reply to contestation of individual claim – S084' where you indicate if you

accept or not the contestation.

CO.8 How do I create 'Credit Note – SED S085'

Optionally, after sending SED S080, at any time in the process, you may fill out 'Credit note' – SED S085 whereby you inform the debtor liaison body about correction of the amount of initial claim in SED S080 that you sent. Each individual credit note must refer to a specific invoice. It is not possible to inform an institution of a credit note regarding two separate invoices.

Within one global Credit Note, you inform the Counterparty about Credit Note related to one of more individual claims.

In the Global Part of the Credit Note, you fill in the global information regarding the Credit Note.

In the Individual Part of the Credit Note, you fill in the required information related to the individual credit note(s).

Then you send 'Credit Note' - SED S085 to the Counterparty. You do not issue SED S085 if the claims are already contested by Counterparty. After the contestations are accepted, the individual claims will be removed from the global claim.

If the Counterparty receives from you SED S085, they can optionally fill out 'Contestation of Credit note' - SED S087 and send it to you. (step CO.4)

What should I do If I receive “'Contestation of Credit note' - SED S087" (Step CO.4)

CP.1 What should I do if I have received the

'Claim for reimbursement'- SED S080?

The Case Owner creates the 'Claim for reimbursement' – SED S080 by entering all required global and individual information claim on the basis of actual cost and sends it to you.

You receive SED S080 and revise this document, then create the 'Acknowledgment of claim for reimbursement' - SED S081 to confirm the receipt of the request and send it to the Case Owner.

If you agree with the Claim for reimbursement you can send to the Case Owner 'Information on payment of individual claim' SED S091 where you inform Case Owner about the schedule for payment. A specific payment announcement always refers to a specific 'Claim for reimbursement' - SED S080. As a response you will receive SED S092.

Alternatively, depending on the circumstances of the case, any of the below steps can occur/be taken:

You may fill out 'Contestation of individual claim' – SED S082, where you as the debtor state notify the amount to be contested and the reason for refusal. As a response you will receive SED S083. (step CP.4) and also SED S084 (Step CP.5)

You can send to the Case Owner ‘Information on down payment' – SED S089' if you want to make a down payment on the claims submitted in Claim for reimbursement' - SED S080. The exact amount of the down payment is determined by the details in the global note claim of SED S080. As a response you will receive SED S090. (step CP.2)

I have received 'Acknowledgement of payment of single claim' - SED S092. (step CP.4)

CP.2 What should I do if I have received the 'Reply to information on down payments' - SED S090?

After the Case Owner receives from you 'Information on down payment' – SED S089 you will receive a 'Reply to information on down payment' – SED S090, informing you on whether the offer is accepted or not. If the offer is accepted, the amount agreed upon should be processed for payment.

The process for Down Payment finishes here.

You may optionally fill out 'Contestation of individual claim' – SED S082, where you as the debtor state notify the amount to be contested and the reason for refusal. As a response you will receive SED S083 and S084.

I have received 'Acknowledgment of contestation of individual claim' - SED S083. (step CP.3)

CP.3 What should I do if I have received the 'Acknowledgement of contestation of individual claim' - SED S083?

After the Case Owner receives from you 'Contestation of individual claim' – SED S082, you will receive an 'Acknowledgment of contestation of individual claim' - SED S083, where the Case Owner confirms the receipt of the contestation of a claim, and a 'Reply to contestation of individual claim – SED S084' where the Case Owner indicates a final status of the contestation.

I have received 'Reply to contestation of individual claim' - SED S084. (step CP.5)

CP.4 What should I do if I have received the 'Acknowledgement of payment of single

claim' - SED S092?

After the Case Owner receives from you SED S091, where you announce the schedule for payment and which invoices will be paid, the Case Owner will fill out 'Acknowledgment of payment of single claim' – SED S092 confirming the receipt of the payment for a claim and send it to you.

If you receive 'Acknowledgment of payment of single claim' – SED S092, then the business use case ends here.

Alternatively you may fill out 'Contestation of individual claim' – SED S082 within the deadline of 18 months, where you as the debtor state notify the amount to be contested and the reason for refusal. As a response you will receive SED S083. (step CP.3) and SED S084 (Step CP.5)

I have received 'Reply to information on down payment' - SED S090 (step CP.2)

CP.5 What should I do if I have received the 'Reply to contestation of individual claim' - SED S084?

You will receive 'Reply to contestation of individual claim' – SED S084, optionally with relevant attachments, confirming or arguing the contestation invalidity.

The contestation claim process finish here.

You may optionally fill out another 'Contestation of individual claim' – SED S082, where you as the debtor state notify the amount to be contested and the reason for refusal. As a response you will receive SED S083 and S084.

CP.6 What should I do if I have received the 'Credit note' - SED S085?

The Case Owner can start a Credit Note process, which informs you as the debtor Liaison Body about correction of the amount of its initial 'Claim for reimbursement' - SED S080. Each credit note must refer to a specific invoice (S080). . It is not possible to inform a Liaison Body of a credit note regarding two separate invoices. Within one global Credit Note, the Case Owner informs you about Credit Note related to one of more individual claims.

In the Global Part of the Credit Note, the Case Owner fills in the global information regarding the Credit Note.

In the Individual Part of the Credit Note, the Case Owner has to fill in the required information related to the individual credit note(s). The Case Owner sends 'Credit Note' - SED S085 to you.

Optionally, you fill out 'Contestation of credit note' – SED S087, where you as the debtor State give information about the contestation of credit note. Then you send SED S087 to the Case Owner which receives it. The Case Owner will send 'Reply on contestation of Credit note' - SED S088 to you.

The Credit Note process finishes here.

I have received 'Reply to contestation of credit note' SED S088. (step CP.7)

CP.7 What should I do if I have received the 'Reply to contestation of credit note' - SED S088?

You receive from the Case Owner 'Reply to contestation of credit note' – SED S088 which gives information about the contestations of credit notes. You review the received SED and the process of Credit Note finishes here.

BPMN diagram for S_BUC_19

Click here to open the BPMN diagram(s) for S_BUC_19.

Structured Electronic Documents (SEDs) used in the process

The following SED is used in S_BUC_19:

S080: Claim for reimbursement (CLA)

S081: Acknowledgment of claim for reimbursement (ACK_CLA)

S082: Contestation of individual claim (COC)

S083: Acknowledgement of contestation of individual claim (ACK_COC)

S084: Reply on contestation of individual claim (RPY_COC)

S085: Credit note (CRN)

S087: Contestation of Credit note (COC_CRN)

S088: Reply on contestation of Credit note (RPY_COC_CRN)

S089: Information on down payments (IDP)

S090: Reply to information on down payments (RPY_IDP)

S091: Information on payment of individual claim (PAY)

S092: Acknowledgement of payment of single claim (ACK_PAY)

Administrative sub-processes

The following technical administrative sub-processes can be used at any point in the process:

AD_BUC_11_Sub-process – Business Exception

AD_BUC_12_Subprocess – Change of Participant